(a) - (c)(No change.) (d)For the purposes of subsection (c) of this section, the underpaid amount is calculated on the ratio of the balance owed by the carrier to the total contracted rate, including any patient financial responsibility, as applied to an amount equal to the billed charges minus the contracted rate. For example, a claim for a contracted rate of $1,000 [$1,000.00] and billed charges of $1,500 [$1,500.00] is initially underpaid at $600 [$600.00], with the insured owing $200 [$200.00] and the HMO or preferred provider carrier owing a balance of $200 [$200.00 ]. The HMO or preferred provider carrier pays the $200 [ $200.00] balance on the 30th day after the end of the applicable statutory claims payment period. The amount the HMO or preferred provider carrier initially underpaid, $200 [$200.00], is 20 percent [20%] of the contracted rate. To determine the penalty, the HMO or preferred provider carrier must calculate 20 percent [20%] of the billed charges minus the contracted rate, which is $100 [$300.00]. This amount represents the underpaid amount for subsection (c)(1) of this section. Therefore, the HMO or preferred provider carrier must pay, as a penalty, 50% of $100 [$300.00], or $50 [$150.00]. (e)(No change.) (f)An HMO or preferred provider carrier is not liable for a penalty under this section: (1)(No change.) (2)if the claim was paid in accordance with §21.2807 of this title, but for less than the contracted rate, and: (A)the preferred provider notifies the HMO or preferred provider carrier of the underpayment after the 270th [180th ] day after the date the underpayment was received; and (B)the HMO or preferred provider carrier pays the balance of the claim on or before the 30th [45th] day after the date the insurer receives the notice of underpayment. (g) - (h)(No change.)
This agency hereby certifies that the proposal has
been reviewed by legal counsel and found to be within the agency's
legal authority to adopt.
Filed with the Office
of the Secretary of State on November 19, 2007
TRD-200705704 Gene C.
Jarmon
General Counsel and Chief Clerk
Texas Department of Insurance
Earliest possible date of adoption: December 30, 2007
For further information, please call: (512) 463-6327
|
